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obesity reviews

doi: 10.1111/obr.12091

Asia

Thailand conquered under-nutrition very successfully but has not slowed obesity
V. Chavasit1, V. Kasemsup2 and K. Tontisirin1

1

Institute of Nutrition, Mahidol University,

Summary
Under-nutrition in Thailand has been successfully controlled for over two decades. However, Thailand is now facing a double-burden malnutrition problem where under- and over-nutrition coexist. Overweight, obesity, and related diseases are the main nutritional challenges, leading to high costs for curative care. Thailand foresees that nutrition can be an effective strategy for preventing diet-related non-communicable chronic diseases, and the country aims to reduce costs for secondary and tertiary health care. Various organizations have conducted national programmes, focusing especially on nutrition education and public campaigns, which have been sustainable and not sustainable. Only milk and certain foods for children are mandated for nutrition labeling. Guideline daily amounts is now the nutrient profile mandated for snack foods in Thailand. To increase efficiency, Thailand’s National Food Committee has been established to link food, nutrition and health via a multi-sectoral approach. Keywords: National campaign, NCD, Thailand.
obesity reviews (2013) 14 (Suppl. 2), 96–105

Salaya, Nakhonpathom, Thailand; 2Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand

Received 13 August 2013; accepted 13 August 2013

Address for correspondence: Mr V Chavasit, Institute of Nutrition, Mahidol University, Phuttamonthon 4th Road, Salaya, Nakhonpathom 73170, Thailand. E-mail: vchavasit@gmail.com

Introduction
Four decades ago, Thailand was still among the developing countries whose populations were suffering from undernutrition and related diseases. At that time, the Poverty Alleviation Plan aimed at achieving basic minimum needs (BMNs), including a reduction in child malnutrition. Community-integrated programmes composed of multisectoral basic services, mass mobilization of volunteers and nutrition indicators were implemented to reach all populations. The ongoing school milk and school lunch programmes are examples of the activities that were originated for solving under-nutrition. Consequently, the prevalence of underweight in preschool children declined from 51% in 1980 to 20% in 1990 and then to below 10% in 2006. Similar to many other Asian countries, Thailand has experienced rapid and continuous economic growth, which provides basic social services and improved living conditions to its general population. Thailand is now classified as

a middle-income developing country. However, emerging nutrition challenges, including overweight and obesity and related chronic diseases, have become a burden for the nation. The increasing rate of overweight and obesity among the Thai population is quite alarming, as are the rising curative costs of non-communicable chronic diseases (NCDs). To address these challenges, the Thai government and stakeholders are implementing preventive rather than curative measures. National strategies have experienced both successes and failures. Several new projects are being planned for future implementation.

Overweight and obesity: current situation
Body mass index (BMI) and waist circumference (WC) are used as the indicators for overweight and obesity in the Thai population. The international cutoff values for both indicators, however, were slightly adjusted so they fit better with the Thai physical status. The BMI cutoff values are

96 © 2013 The Authors. Obesity Reviews published by John Wiley & Sons Ltd 14 (Suppl. 2), 96–105, November 2013 on behalf of the International Association for the Study of Obesity. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

November 2013 . The original nutrition education and communication guides were difficult for people to understand. eating plenty of vegetables and fruits regularly. lean meat.0%. eggs. 22. Nutrition. Even though the country abounds with various types of fruits and vegetables. eating fish. and International Obesity Task Force (4). Food-based dietary guidelines for individuals older than six years were developed along with a food © 2013 The Authors. Chavasit et al. Previous and ongoing nutrition programmes Food-based dietary guidelines and the nutrition flag Established in 1996.7 billion) in 2009. respectively.obesity reviews Thailand policy on NCD prevention V. respectively. Unfortunately. The most up-to-date data in 2009 shows that the percentages of males and females with excessive WCs were 18. animal foods.6% and 45. The nutrition flag or food guide provides information on the proper portions of cereals and other complex carbohydrates. ‘Half fruits and vegetables and half of others’ campaign In 2005. National campaigns encouraging increased fruit and vegetable consumption. The WC cutoff values formerly were 90 and 80 cm for males and females. 2). eating clean and safe food. sugar. nutrition information was provided through nutrition labeling that used a nutrition fact table for processed foods. only during certain periods of certain governments). and those for overweight and obesity were estimated at 12 billion baht (US$400 million). vegetables. In 2010. International Association for the Study of Obesity. Thailand saw overweight and obesity and related diseases as challenges that could be prevented via nutrition education. which is much lower than the 400 g per day recommended by the Food and Agriculture Organization of the United Nations (3) and the World Health Organization. salt. regular exercise. In addition.0 kg m−2 for overweight and obesity.9 and 25. The concept was quite easy to understand and practical and thus was widely adopted (Fig. 1). and avoiding or reducing consumption of alcoholic beverages (Table 2) (5). Thailand’s food-based dietary guidelines recommend maintaining proper weight and eating a variety of foods from each of the main food groups. Medical expenses for NCDs were estimated at 140 billion baht (US$4. and Linking Food. drinking milk of appropriate quality and quantity for one’s age. legumes and pulses. Food Quality and Safety. this campaign was discontinued in 2006 due to a lack of funding. consuming an appropriate amount of fat. the Ministry of Public Health launched a campaign to promote diets that are half fruits and vegetables and half other foods. Another indicator related to NCDs is the amount of fruits and vegetables consumed by a population. National programmes for controlling overweight and obesity Initially.e. but they have been changed (2013) to half of an individual’s height. Later the guideline for daily amounts (GDA) was added to the label. cardiovascular diseases and stroke were the leading causes of death among the Thai population (Table 1). fruits. NCDs became a significant public health problem for Thailand during the last decade. guide model presented as a hanging flag. and fat one should consume daily (Fig. The third committee addresses NCDs as a priority issue and has several subcommittees working on the following specific issues. the suggested portions were modified to reflect familiar serving utensils (Fig. and legumes and pulses regularly. 96–105. 2) (6). Obesity Reviews published by John Wiley & Sons Ltd on behalf of the International Association for the Study of Obesity 14 (Suppl. eating an adequate amount of rice or alternative carbohydrates. and Health. the National Food Committee. chaired by the prime minister. developed the Strategic Framework for Food Management in Thailand (SFFM). Thai males consume on average only 268 g per day and Thai females 283 g per day (Health Examination Survey 2003–2004) (2). in line with the government policy. which was approved by the cabinet in November 2010. and monitoring and control of WCs were implemented inconsistently (i. Consequently. In 2011. Ministry of Public Health surveys performed in 1995–2009 indicated that the number of Thai school children who were overweight and obese (based on weight by height) was increasing continuously (Fig. respectively (1). 4) (7). 97 Figure 1 Prevalence of overweight and obesity among school children (ages 6–14 years). avoiding sweet and salty foods. The SFFM is currently implemented through three committees: Food Security throughout the Food Chain. 3) (6) and are now more useful for dietitians and food counselors.

Thailand’s Food and Drug Administration (FDA) decided to implement the guideline for daily amounts (GDA) for these three nutrients on a voluntary basis except for snacks. especially at the community level (Fig.and over-nutrition and related NCDs. The format of Thailand’s nutrition fact table is similar to that of the US Food and Drug Administration. NCD. Its implementation for other food products is still doubtful. Ministry of Public Health 2013. Drink milk of appropriate quality and quantity for one’s age. 2). November 2013 . the Ministry of Public Health implemented nutrition labeling on a voluntary basis except for milk and milk products and food products that make nutrient claims. Eat fish.00 Table 1 NCD prevalence and death rates in 2011 Cardiovascular diseases Stroke Diabetes mellitus Hypertension Source: Bureau of Policy and Strategy. edge that will help them choose the right nutrients for their health.9 5. 5) (9). Food-based dietary guidelines • • • • • • • • • Eat a variety of foods from each of the five food groups and maintain proper weight. the Ministry of Public Health has conducted various national campaigns that promote regular exercise or physical activity. Obesity Reviews published by John Wiley & Sons Ltd on behalf of the International Association for the Study of Obesity 14 (Suppl. not one serving. Chavasit et al. academicians.98 Thailand policy on NCD prevention V. and legumes and pulses regularly.e. 96–105.75 848. obesity reviews NCD Death rate per 100. Public areas for exercise have been arranged in many workplaces and communities. Eat an adequate amount of rice or alternative carbohydrates. This application may be realistic only for snack products. eggs. the GDA concept is not acceptable to either the food industry or academicians. lean meat. Most local authorities have allocated budgets to facilitate these activities. the nutrition fact table is used to enhance the image of a food product rather than to provide nutrition knowledge to consumers.000 population 935. 6) (10). As the middleman.4 30. saturated fatty acids. Table 2 Thailand’s food-based dietary guidelines Nutrition fact table In 1998. Avoid sweet and salty foods. Another side blamed the traffic light symbol for causing more confusion and misleading consumers. The Thai GDA is slightly different from others.187. © 2013 The Authors. and the food industry. since the interpretation is based on one package. Eat clean and safe food.7 Prevalence rate per 100. but it is complicated and therefore difficult for general consumers to understand (Table 3) (8).77 1.92 277. especially for the elderly. especially consumer protection agencies. since consumers almost always eat the entire package of a snack at one time (Fig. Furthermore. Several public and private organizations have also adopted this concept. This issue was hotly debated by health policy lobbyists. The nutrition labels clearly aim to prevent both under. Avoid or reduce the consumption of alcoholic beverages.0 11. Eat plenty of vegetables and fruits regularly. One side claimed that consumers have the right to knowl- Campaign for regular exercise and physical activity Since 2009. Since labeling is voluntary for most food products. regardless of package size. Academic and health policy people in Thailand in fact prefer the traffic light model. nongovernmental organizations (NGOs). Eat a diet containing appropriate amounts of fat. sugar and sodium). non-communicable chronic disease. This campaign seems to be quite successful. The nutrition fact table in Thailand thus makes a food product look good but has little impact on knowledge about its nutrition and appropriate consumption. Guideline for daily amounts During the last two decades academicians and consumer protection agencies made requests to the Ministry of Public Health to create a nutrition profile for all food products that included a traffic light designation for at least three nutrients (i.000 population 31.

sugar and salt Eat only in limited amounts For good health. 96–105. This campaign could have garnered high public interest. November 2013 . ‘Foods for Children’ control The Thai FDA and the Public Relation Department issued the regulation on commercialization of ‘Foods for Children’. 99 NUTRITION FLAG HEALTHY EATING FOR THAIS Rice-starchy food 8-12 rice serving spoons Vegetable 4-6 rice serving spoons Fruit 3-5 portions Milk 1-2 glass(es) Meat 6-12 spoons Oil. 7) (11). including sweetened carbonated beverages. ‘Thai People Have Flat Belly’ campaign The campaign ‘Thai People Have Flat Belly’ aimed at promoting healthy behaviour on food consumption and physical activities for Thai people to reduce non-communicable diseases by using their WC’s as indicators for self monitoring. The campaign endorsed banning sugary beverages from schools. 8) (13). A national law prohibiting added sugar in follow-up infant formulas was one of the successes of this network. Similar campaign with more in depth investigation was led by the Royal College of Physicians of Thailand under the title ‘Network of Fatless Belly Thais’ with the same objectives but also aiming for reducing intraabdominal adiposity and metabolic syndrome for Thai people (13). Under this campaign concept. eat a variety of food in appropriate amounts Figure 2 Thailand’s nutrition flag. Obesity Reviews published by John Wiley & Sons Ltd on behalf of the International Association for the Study of Obesity Sweet Enough Network The Sweet Enough Network was established by a group of dentists.obesity reviews Thailand policy on NCD prevention V. and added sugar from follow-up infant formulas (14). which limits the advertisement periods of foods for children from television prime times for children and family 14 (Suppl. © 2013 The Authors. Chavasit et al. pediatricians and public health workers in the Ministry of Public Health’s Dental Health Division to endorse regulations to reduce added sugar in food products. and the public has learned the cutoff values for healthy WCs (12). the Thai Health Promotion Foundation also funded a television series of the mentioned network with the collaboration of the Thai Public Broadcasting Service (Thai PBS): The firm. Fat Fact (Fig. 2). Its intervention ranges from national to local authorities. as it involved high-ranking politicians (Fig.

Nutrition. obesity and related diseases under the National Food Committee Since the Thai cabinet established the National Food Committee in 2010. © 2013 The Authors. As being surveyed by a consumer protection agency in 2010. Exercise More’ is required on the label of the product classified as unhealthy. these regulations are still violated widely (15).100 Thailand policy on NCD prevention V. physical. Chavasit et al. and Health have actively pursued the following projects. a toy is not allowed to be sold along with foods for children. Obesity Reviews published by John Wiley & Sons Ltd on behalf of the International Association for the Study of Obesity Figure 4 The ‘Half Fruits and Vegetables and Half Others’ campaign. 2). several subcommittees. Moreover. and biochemical standards and indicators used for evaluating nutritional status and NCDs in the Thai population. is still not clearly active on the policy of food marketing for children. November 2013 . and warning sign as ‘Eat Less. obesity reviews 1 plate of rice 1 bowl of noodle 1 slice of bread = = = 3 rice-serving 2 rice-serving 1 rice-serving spoons spoons spoons 1 piece of fermented noodle = 1 rice-serving spoons 1 ear of corn = 1 rice-serving spoons kale = 1 rice-serving spoons pumpkin = 1 rice-serving spoons 2 tomatoes = 1 rice-serving spoons Ivy gourd = 1 rice-serving spoons 1 banana = 1 portion 1 orange = 1 portion 6 pieces of papaya = 1 portion 1 chicken drumstick = 2 spoons 1 egg = 2 spoons 1 mackerel = 2 spoons 1 tofu = 4 spoons milk = 1 glass yogurt = 1 cup Figure 3 Use of household units for Thailand’s food-based dietary guidelines. • Standards and indicators for nutrition and NCDs The committee has revised existing anthropometric. 96–105. • Food-based dietary guidelines for different age groups Food-based dietary guidelines for specific age groups other than the general population have been developed. The control of radio and television advertisements which just have been transferred to the Office of 14 (Suppl. task forces and working groups within the committee on Linking Food. the National Broadcasting and Telecommunications Commission (NBCT). (12 min per hour). Current programmes: planned and pilot implemented Projects on overweight.

Gram. Consumption should be split into……times.400 mg Calories per gram: fat 9. are based on 2.. 2). Sodium _____ Milligram *…% *…% *. sodium. carbohydrate 4 The boldface is normally for the main nutrients. • Increase fruit and vegetable consumption The committee has accumulated available knowledge on the health benefits of fruits and vegetables. The Ministry of Public Health has adopted a successful community-based programme for the alleviation of maternal and child under-nutrition to help solve the emerging NCDs problem. • Food. and fat in diets Identification of contributing sources of sugar. Sugar _____ . mostly in the countryside and in 27 schools in Bangkok under the patronage of Her Royal Highness Princess Maha Chakri Sirindhorn...5 g 18% Cholesterol 0 mg % Protein 6g Total carbohydrate 10 g 3% Dietary fiber 2g 8% Sugars <1 g Sodium 100 mg 4% Percent Thai RDI* 4% Vitamin A 0% Vitamin B1 4% Calcium 0% Vitamin B2 Iron 4% *Percent Thai Recommended Daily Intake for Thai population over 6 years of age. Chavasit et al... nutrition. especially local varieties. 101 Table 3 Thailand’s nutrition labeling Nutrition information Serving size: 1/2 bag 25 g Serving (s) per bag: 2 Amount per serving Total energy 130 kcal (Energy from fat 60 kcal) Percent Thai RDI* Total fat 7g 11% Saturated fat 3. and dietetic education for different age groups Appropriate educational tools have been developed at the community level for transferring food and nutrition knowledge to promote healthy nutrition and good health and to prevent diet-related NCDs.% *.obesity reviews Thailand policy on NCD prevention V. November 2013 . They will work jointly with the subdistrict hospital to promote health and nutrition and provide services to all community people using a life course approach that extends from antenatal care to care for the elderly. • Reduction of sugar. Fat _____ …Gram.. Energy requirement vary by individuals. Energy _____ …Kcal. It is 14 (Suppl. If your activities require energy of 2.% *Percentage of maximum consumption volume allowed per day Figure 5 Format of the Thai FDA’s GDA labeling. your daily should provide the following nutrients: Total fat Less than 65 g Saturated fat Less than 20 g Cholesterol Less than 300 mg Total carbohydrate 300 g Dietary fiber 25 g Sodium Less than 2... has demonstrated key success factors that are economical and can be used for expansion into other schools. and developed consumption-promotion strategies. such as consumer campaigns. sodium and fat in the Thai population has facilitated the development of appropriate strategies.000 kcal diet. • Community-based food and nutrition programme to promote healthy nutrition and healthy people while controlling and preventing obesity and related NCDs © 2013 The Authors. protein 4.. • School-based food and nutrition Evaluation of the ideal model for food and nutrition management in schools. The ministry plans to actively involve existing volunteers (1 per 10 households) in every part of the country. 96–105. food product development in the industry and school education. to manage the most common sources. Obesity Reviews published by John Wiley & Sons Ltd on behalf of the International Association for the Study of Obesity Nutritional value per…….000 kcal per day.

• Annual national survey for nutrition status and NCDs An attempt is being made to conduct an annual national nutrition survey instead of the 5. espe- cially among children. and 14 (Suppl. applying tax and price policies to unhealthy foods. Food supports during and after a crisis are being planned in a sustainable way and through nutrition awareness. obesity reviews Figure 6 Exercise is offered in workplaces and communities under the national campaign. • Food and nutrition management during crisis The massive flood in 2011–2012 made it clear that Thailand must become better prepared for food and nutrition security during crises. Obesity Reviews published by John Wiley & Sons Ltd on behalf of the International Association for the Study of Obesity . This strategy would allow the country to identify nutrition problems more promptly and solve them in a more timely manner. a participatory-policy process to promote healthy public policy on major health problems in Thailand. (v) strengthen health services and programmes to mitigate problems associated with overweight and obesity. Chavasit et al. and information collection will be centrally designed and carried out by local public health and nursing schools around the country. brought the issue of overweight and obesity to the second National Health Assembly. (iv) promote physical activities. 96–105. The survey topic. and (vi) strengthen an overall system to address and monitor obesity and overweight and a system to evaluate related programme. In mid-2010. the working group drew up a framework for developing an action plan with six key areas: (i) promote breast-feeding and healthy diets. aimed at promoting good nutrition and good health and reducing the need for secondary and tertiary health care. November 2013 © 2013 The Authors. The National Health Assembly. and passed a resolution intended to adopt a national strategies and to develop an action plan for management of overweight and obesity in 2009 (16–18). Resolution on overweight and obesity of the National Health Assembly Overweight and obesity have emerged as potential public health problems in Thailand during the past decade. (iii) raise public awareness about the risks of obesity and overweight through public communication. The national action plan to fight overweight and obesity was drafted and sent back to the National Health Assembly in 2011 with updated situations of the resolution in 2009 on implementing traffic light labeling of processed food.to 10-year round. (ii) control the marketing of food for children. 2). sample population.102 Thailand policy on NCD prevention V.

‘OK’ symbol for ok products: potential Thailand’s Future Programme On 11 February 2013. Thailand. implementation has been slow. food industry representatives. In addition. Most stakeholders. Mahidol University. 2).obesity reviews Thailand policy on NCD prevention V. 96–105. © 2013 The Authors. November 2013 . It is expected that the ‘OK’ symbol will be a tool to help consumers choose the right food products for their health and to encourage food industries to take a healthy direction in developing food products.e. Professor Barry Popkin presented ‘Regulatory Options Being Utilized to Address Rising Nutrition-Related Noncommunicable Diseases’ at the Institute of Nutrition. Consequently. it was a positive approach and did not classify any type of food as poison. This ‘OK’ system Popkin presented was based on the Mexican government’s experience in adapting an international system whose criteria were set by an independent group of nutrition scientists and which has been adapted to a number of countries globally. The ‘OK’ symbol will be issued to qualifying food products with quality monitoring by an independent organization. A paper discussing this system was published earlier (19). the Thai FDA and health policymakers were receptive to this presentation and would like to test the ‘OK’ concept. 103 controlling the marketing of energy-dense and unhealthy foods that target children Even though the National Health Assembly has introduced these impressive recommendations for a national plan to fight overweight and obesity. Figure 8 Television series of the Thai Health Promotion Foundation and the Thai Public Broadcasting Service to campaign against overweight and abdominal obesity. sodium and sugar) in each commercial food product. it may take some time to set up criteria and achieve agreements among stakeholders. They felt that the concept was clear and would not cause confusion among the consumers. including academicians. a measure to raise awareness and commitment among nonhealth agencies has become an issue. Figure 7 The ‘Thai People Have Flat Belly’ campaign. Chavasit et al. Obesity Reviews published by John Wiley & Sons Ltd on behalf of the International Association for the Study of Obesity 14 (Suppl. However. since several agencies other than health agencies have had to be involved. saturated fatty acids. The Thai FDA will establish the ‘OK’ criteria based on the contents of three nutrients (i.

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